Recording of physician notes and subsequent medical transcription to create transcripts is an effective means of ensuring that all clinical details are correctly documented. However, the entry of electronic health records has changed this practice and providers are now required to enter patient details into the EHR system. Work pressure, difficulty to attend to the patient and make inputs into the EHR simultaneously may be challenging for many providers resulting in inconsistent and erratic documentation.
The Woes of Documentation
A recent study published in an international journal, Patient Education and Counseling found that very few patients are asked if they take dietary supplements upon hospital admission and had their use documented when in fact, more than half of the patients used DS before hospitalization. Around 558 hospital patients were included in the study and 333 patients (60%) used dietary supplements prior to hospitalization. Out of 333 patients, only 36% had their supplement use documented at the time of hospital admission while only 18% told their provider about supplement use and only one in five were asked about their supplement use by the provider. Only 6% met all the criteria in an ideal scenario – asking about dietary supplement at admission, disclosing the use of products and documenting their use in medical charts.
A 2014 study published in the Journal of the American Geriatrics Society found incomplete discussion and documentation of supplement use with older adults during their visits to the primary care office. Most of the patients (60%) who reported taking dietary supplements during the study had a mean age of 64.6 ± 10.1. Around 56% (142/256) of the patients reported taking at least one supplement, their visits audio-recorded and medical records abstracted. Though 59% of these 142 patients discussed at least one of their supplements during their visit to a primary care provider and 58% had at least one supplement documented in their record, only 7% discussed all their supplements and only 13% had all their supplements documented during primary care visits. Only 5% of patients both discussed all their supplements and had all of them documented during their visits. Overall, the number of supplements patients were taking did not correlate with supplement discussions or documentation in this study.
EHR Integration and Transcription Could Improve Documentation
To put it in a nutshell, there is a growing need to educate physicians about the potential risks of medications and supplements and the importance of asking patients, especially older patients, proactively about supplement use and documenting their use. Lack of such knowledge may cause physicians to provide a treatment or prescribe a medication that could have an adverse reaction with the supplement and that would in turn affect patient safety. Though physicians can make use of a well-designed EHR to expedite their documentation process, limitations to narrative description may still make the documentation incomplete. Moreover, errors can occur due to frequent copy pasting of information without proper checking. EHR Integration and transcription would be an ideal choice in which the audio recordings of patient visits are transcribed, thoroughly checked for quality and the details entered into relevant EHR fields.
